The Bitter End

By Mary Kay SchoenApril 22, 2003

Of my parents' 56 years of committed but contentious marriage, the final two were the most difficult. My mother at 80 could neither see nor walk well. A gregarious woman now unable to drive, read or sew, she was largely confined to their apartment with my 82-year-old father, who couldn't hear well and had never been a great listener. Cabin fever set in.

Little irritations became Big Issues.

"Why can't you anticipate?" Dad would complain as Mom came around the corner pulling her portable oxygen tank and banged the doorway for the umpteenth time.

"Why can't you do something about your papers all over the floor?" she would shoot back.

In the close quarters, these old, unresolved hurts resurfaced and festered. Mom sniped, Dad roared; she sank into depression, he withdrew into his newspapers.

Yet this same couple had made it together through stillbirth and business failure, heart surgery and cancer. What was going on here? Surely our parents deserved a better last chapter for their lives, my brothers and I told one another during anguished long-distance phone calls. After antidepressants, family outings and pep talks failed to heal the wounds, we finally found a family therapist willing to come to their apartment. Two weeks later, when we had nearly persuaded them to make an appointment, my dad died in his reading chair.

Look for variations on this scene to play frequently as health care prolongs life and the population of "old marrieds" grows. In 2000, according to U.S. Census data, 6.5 million Americans 75 and older were married and living with their spouses, more than three times as many as in 1960. "Retirement living" communities may project images of smiling seniors dancing the night away, but the reality is more sobering. As older couples weather health crises and relinquish long-held roles, resulting stresses can tear at even strong marriages, say experts, and the mental health community is not adequately prepared to help.

While far more psychologists work with elderly clients than a decade or two ago, according to Sara Honn Qualls, psychology professor and director of the Center on Aging at the University of Colorado at Colorado Springs, most have had little or no formal training in dealing with the aged. "We are not educating enough people in the mental health disciplines to meet the projected needs of older people," says Qualls. And while a large body of literature covers such "geropsychological" topics as depression and caregiving, there's little research about long-term marriage on which to build clinical practice.

"Out of 115 longitudinal studies of married couples that we have found, there are only three following middle-aged or older couples," said psychology doctoral candidate Kim McCoy at the University of California, Berkeley. She and her professor are working on one of them, a 12-year-old descriptive study following 36 couples.

Meanwhile, many older couples are facing mental health crises.

"A couple may have had a good marriage -- or maybe they didn't but they were living separate lives and adapted to the spouse's behavior -- but as the couple attempts to cope with trying new circumstances, at some point what was tolerated can become unbearable," said Melissa Berenson, a Reston social worker who specializes in counseling the elderly.

Few accept help easily even if they know where to find it and have insurance that will cover some or all of the costs. Members of my parents' generation, say those who work with them, are often deeply skeptical of therapy's value and feel that accepting treatment is a sign of moral weakness or psychosis.

Integrity vs. Despair

Every stage of life, including the final one, has specific tasks, wrote psychoanalyst Erik Erikson. Just as 2-year-olds need to learn to say "no" to become separate persons and young adults need to foster intimacy to create stable relationships, those in their seventies and eighties need to come to terms with what was and what is -- often two different things. Erikson termed the challenge "integrity vs. despair."

Experts say even couples who make an easy transition to retirement -- enjoying leisure, travel and grandchildren -- can have a crisis creep up on them, as it did for my parents. Declining sight, hearing or mobility, increasing isolation or the beginnings of dementia can be the stimulus. Or the crisis might be a sudden one, such as the loss of a driver's license, the death of the last old friend or a debilitating stroke.

"Somebody can be a very young 95 or an old 68," said Marcia Hinkle, a counselor at Brookland Pastoral Center in Washington and former director of social services at a large nursing home. "Sometimes the difference between 'young old' and 'old old' is a single health event."

Therapy reaches some couples through the back door: In the course of providing social services -- transportation, activity, medical assistance -- for aging couples, adept geriatric care managers often sneak in a little counseling for fractious, unhappy parents -- and for their stressed-out children as well.

"I worked with one couple who were hard to be around because of their constant bickering," says geriatric psychotherapist Grace Lebow, co-founder of Aging Network Services in Bethesda. When neither party could drive any longer, their children seized this opportunity to get Lebow in the door as a "geriatric resource specialist." While she met with them weekly about transportation and other needs, Lebow established a bond and did informal counseling. "I listened to them both," she said, "giving each a chance to talk. A care manager can act as a role model for treating the other person with respect."

Changes in the environment also helped. Lebow persuaded the woman to try day care, which would offer her some positive stimulation and allow her husband some time to himself. When the care team established that the woman's forgetfulness, which had been aggravating her husband, was probably the beginning of Alzheimer's disease, Lebow counseled the husband, sympathizing with him and helping him understand why his wife was frequently irritable.

It's familiar terrain for geriatric counselors.

Explains Hinkle, "When people get onto the leading edge of Alzheimer's, there is a complicated emotional reaction to realizing that you're not 'getting it' -- extreme fearfulness and a lot of anxiety. It's often expressed in irritation, anger or impatience: 'I can't find my keys. You moved them!'" Meanwhile, says Berenson, the healthy member of the pair "may be in great denial and will push the spouse further than he or she can go."

The Age Factor

Age, agree many therapists who work with older clients, is less a predictor of success with counseling than is motivation for change.

Hinkle counseled one couple in their mid-seventies who had moved to a small city apartment from a six-bedroom house in the country. Without the buffer of space they had come to rely on, their level of conflict increased dramatically.

"But," said Hinkle, "they were game -- open to trying new things. It was almost like working with a much younger couple. I took them through basic communication exercises around conflict management and anger management. They learned to manage issues they'd previously avoided by being apart a lot. It also emerged that she was at the beginning of a dementia process. Once he understood that, he was able to be significantly more patient."

Jim Osterhaus, a Northern Virginia clinical psychologist, has also seen the difference attitude makes. "One older man told me, 'All I want you to do is teach my wife to shut up.' We didn't get very far." But I see another man -- he's 72 and his wife is 60. They bicker constantly. She won't come in at all, but he and I chat every few weeks about his own part in the problems -- how he is forwarding or hindering the relationship."

Easing the pain often calls for new communications skills: learning how to listen to the other's complaint and to express needs without pushing hot buttons. "Those skills are not part of that generation's culture," observed Jeanne Snapp, a licensed clinical social worker in Fairfax County. She often uses stories about third parties to make a point in a non-threatening way and will teach clients how to listen and reflect back what they hear.

Michael Herr, a family psychiatrist at Georgetown Family Center, a private nonprofit clinic, says his first task is helping clients see hidden patterns in family relationships that may feed quarrels between aging spouses. "After talking here," he says one woman told him, "I realized I wasn't the one responsible for fixing this problem."

Cognitive behavioral therapy -- in which clients dissect their behaviors rationally, analytically -- is one common approach used with long-marrieds. A contrasting approach, called Emotionally Focused Couples Therapy (EFT), was pioneered by Sue Johnson, professor of psychology and psychiatry at the University of Ottawa and director of the Ottawa Couple and Family Institute. "In long-term relationship you're more likely to have significant hurts," says Johnson. "We know that time doesn't touch trauma; it just goes into the background. Then there comes a time when your spouse needs you very much -- and the hurt comes screaming out of the past." Bingo. She was describing my distressed parents.

"How could you have bought a house -- our first house -- without asking me?" Mom would demand. "How could you not tell me when the business was failing?"

"That was 51 years ago," Dad would reply, shaking his head. "I just do not understand women."

Instead of counseling a couple having money quarrels to avoid flash points and negotiate a plan giving the wife more say in financial decisions, EFT would lead the couple to probe the feelings behind their anger and come to acknowledge their emotional dependence on one another. Research confirms that this approach can be quite effective: In a 1999 analysis of four EFT studies reported in the Journal of Clinical Psychology, almost three-quarters of couples treated with EFT were found to be recovered from distress upon follow-up and 90 percent showed significant improvement.

Hard Cases

No matter what the therapy, some situations don't resolve easily.

Depression in the face of losses and the knowledge that life is ending is common, say experts. Snapp sees "a lot of grieving inside. Men especially tend to keep it in, and it often comes out as anger or hostility." She often does grief therapy with older clients -- "though I don't call it that," she says.

Children can be too accepting of parental depression, says Hinkle.

"Often when I would talk with adult children about their parents in residential care," she recalled, "I'd say, 'I think your mom is depressed, and I'd like to have a psychiatrist do an assessment.' Their response often was, 'Who wouldn't be depressed?' The implied logic was, 'Why should we bother to treat it?' "

There are personalities, too, that are so difficult -- manipulative or irrational -- that help is limited.

"Sometimes all you can do is help a couple to be less miserable," Lebow cautions. She distinguishes between a reasonably healthy relationship threatened by stress and a marginal one. In already-difficult marriages, where there are deep-seated, long-term problems such as addictions or personality disorders, the additional stresses that so often accompany old age can upset a precarious balance.

"Often the adult children are having more difficulty than parents in accepting a difficult situation and they are the ones who will benefit most from counseling," says Berenson.

Lebow concurs. "Sometimes," she says, "they need help to grieve for the parents they never had."

My brothers and I were certainly grieving. Perhaps we stood too close to help Mom and Dad -- and ourselves -- see their losses and failures in balance with their considerable successes as parents, friends and part of a close-knit community. We certainly didn't know how to help them deal with old hurts.

Despite our well-meaning attempts at intervention, they survived their last few years together mostly by drawing on their strong commitment and sheer grit. I believe that with some professional help it could have been easier for all of us.